Clinical Document Specialist (Non-RN) - Remote

Overview

The Clinical Document Specialist collaborates with healthcare professionals to ensure accurate medical record documentation reflecting patient conditions and care.

In Short

• Collaborates with physicians and staff for accurate medical record documentation.
• Reviews inpatient medical records for clinical specialties.
• Communicates with physicians to validate observations and suggest documentation improvements.
• Supports documentation for coding, reimbursement, and quality purposes.
• Works with HIM Coding staff for accurate diagnosis documentation.
• Develops corrective actions for documentation trends.
• Provides education to clinical staff on documentation practices.
• Maintains quality of reviews and compliance with policies.
• Participates in quality improvement initiatives.
• Respects diverse views and maintains professionalism.

Requirements

• M.D., D.O. or equivalent required.
• Experience in direct patient care or case management required.
• 1-3 years of Clinical Documentation Improvement (CDI) experience preferred.
• Knowledge of clinical documentation practices and ICD-10-CM required.
• Excellent interpersonal skills.
• Ability to use specialized computer systems for data analysis.
• Equivalent combination of education and experience may be accepted.

Benefits

• Potential signing bonus.
• Supportive work environment with a focus on respect.
• Opportunities for professional development.
• Comprehensive health benefits.
• Engagement in quality improvement initiatives.